Medicare

General Overview

Medicare is a federal program enacted in 1965 and administered by the The Centers for Medicare and Medicaid Services (CMS). The Medicare Modernization Act of 2003 made significant improvements to Medicare, including the addition of a prescription drug benefit. Generally, Medicare is available for people age 65 or older, younger people with disabilities and people with End Stage Renal Disease (permanent kidney failure requiring dialysis or transplant).

The Social Security handles Medicare eligibility and enrollment. You can contact the Social Security Administration at 1-800-772-1213 to enroll in Medicare or to ask questions about whether you are eligible. You can also visit their web site at www.socialsecurity.gov

Medicare Parts A and B

Medicare has two parts, which help pay for different kinds of health care costs.

Medicare Part A (Hospital Insurance) helps cover your inpatient care in hospitals, critical access hospitals and skilled nursing facilities. It also covers hospice care and some home health care, if you meet certain conditions. Most people do not have to pay a monthly premium for Part A because they or their spouse paid Medicare taxes while working.

Medicare Part B (Medical Insurance) helps cover your medically necessary doctors' services, outpatient hospital care and some other medical services that Part A does not cover, such as some of the services of physical and occupational therapists and some home health care. A monthly premium is required for Part B.

If you and/or your spouse are not enrolled in Medicare Part A or B at age 65, Health Plan benefits may be reduced. When you lose “active” coverage under the Laborers' Welfare Fund Plan and become eligible for either the Retiree Medical Plan, the Basic coverage, Medicare will become your primary payor and the Laborers' Welfare Fund Health Plan your secondary payor. The Plan rules provide that if you are not enrolled in Medicare when Medicare is primary and the Laborers' Welfare Fund Health Plan is secondary, the Laborers' Welfare Fund Health Plan benefits will be reduced by 80%. You are responsible for the remainder of the charges.

Medicare Part D

Effective January 1, 2006, a new voluntary prescription drug benefit, Part D, was offered and involves a monthly premium.

Medicare Prescription Drug Plans (PDPs) are available for Medicare eligible retirees starting January 1, 2006. Private insurance carriers create and administer the PDPs and charge individuals a monthly premium for the coverage.

Medicare PDPs vary in what prescription drugs are covered, how much you have to pay, and which pharmacies you can use. All PDPs have to provide at least a standard level of coverage, which Medicare establishes. However, some plans offer more coverage and additional drugs for a higher monthly premium. If you enroll in a Medicare PDP, it is important for you to choose one that meets your prescription drug needs.

If you are in the Laborers' Welfare Fund Health Plan, you already have prescription drug coverage through CVS/Caremark that is more generous than the Medicare coverage, as shown below; therefore, you do not need to enroll in a Medicare PDP. You can be in either the Laborers' Welfare Fund Health Plan or a Medicare PDP, but not both. If you decide to join a Medicare PDP, then the Laborers' Welfare Fund Health Plan will not provide you with any prescription drug coverage.

Medicare and End Stage Renal Disease

End Stage Renal Disease (ESRD) is a reason for entitlement to Medicare for patients of any age.

There is usually a three-month waiting period from the time a patient begins maintenance dialysis before becoming eligible for Medicare. Eligibility begins with the third month after the month the patient begins a course of maintenance dialysis treatment. If the patient is receiving self-dialysis, the three-month waiting period is waived. Coverage will begin the first month of dialysis if the individual is expected to complete the self-dialysis training program and self-dialyze thereafter.

If a patient receives a kidney transplant, the three-month waiting period is also waived. Coverage begins the month a patient is admitted to an approved hospital for a kidney transplant or preliminary transplant procedures and the transplant takes place within that month or the following two months. If the transplant is delayed more than two months after the beneficiary is admitted to the hospital for the transplant procedures, Medicare eligibility begins two months before the month of the transplant, or if earlier, the first day of the third month after the month maintenance dialysis began.

The Laborers' Welfare Fund Health Plan will be primary to Medicare for the first 30 months after Medicare eligibility begins (regardless of whether or not the patient actually enrolls in Medicare). This 30-month period is referred to as the ESRD coordination period. At the end of this period, Medicare becomes primary.

It is possible that an employment sponsored retirement policy may be primary to Medicare. If a patient retires prior to age 65 (not entitled to Medicare due to Age) and continues to carry his employer sponsored group health plan and then becomes entitled to Medicare due to ESRD, that group health plan would be primary to Medicare for the 30-month coordination period.

Medicare coverage will end 12 months after a patient no longer requires maintenance dialysis or 36 months after a successful transplant (provided ESRD is the only reason for entitlement). Coverage can be reinstated without a waiting period if dialysis resumes or if the patient receives a transplant within 12 months after the dialysis ended or if either occurs within 36 months after a transplant. If an individual has more than one period of entitlement based on ESRD, a coordination period is determined for each period of entitlement. In the case where a kidney transplant fails and the individual requires dialysis after the 36-month period of Medicare entitlement, the 30-month coordination period begins with the month of maintenance dialysis. A second waiting period is not required for re-entitlement to Medicare for situations involving kidney transplant failure.

Medicare Covered Preventative Services

One-Time “Welcome to Medicare” Physical Exam - Medicare covers a one-time preventive physical exam within the first 12 months that you have Part B. The exam will include a thorough review of your health, education and counseling about the preventive services you need, like certain screenings and shots, and referrals for other care. The "Welcome to Medicare" physical exam is a great way to get up-to-date on important screenings and shots and to talk with your doctor about your family history and how to stay healthy.

Cardiovascular Screening - Medicare covers cardiovascular screenings that check your cholesterol and other blood fat (lipid) levels. High levels of cholesterol can increase your risk for heart disease and stroke. These screening tests will tell if you have high cholesterol. You might be able to make lifestyle changes (like changing your diet) to lower your cholesterol and stay healthy. Medicare will cover these tests every five years.

Shots (Flu, Pneumococcal, Hepatitis B) - Medicare covers flu, pneumococcal, and Hepatitis B shots. Flu, pneumococcal infections, and Hepatitis B can be life threatening to an older person. All adults 65 and older should get flu and pneumococcal shots. People with Medicare who are under 65 but have chronic illness, including heart disease, lung disease, diabetes or end-stage renal disease should get a flu shot. People at medium to high risk for Hepatitis B should get Hepatitis B shots.

Bone Mass Measurements - Medicare covers bone mass measurements to determine whether you are at risk for a fracture (broken bone). People are at risk for fractures because of osteoporosis. Osteoporosis is a disease in which your bones become weak. In general, the lower your bone density, the higher your risk is for a fracture. Bone mass measurement test results will help you and your doctor choose the best way to keep your bones strong.

Diabetes Screening - Diabetes is a medical condition in which your body doesn't make enough insulin or has a reduced response to insulin. Diabetes causes your blood sugar to be too high because insulin is needed to use sugar properly. A high blood sugar level is not good for your health. For people with Medicare at risk for getting diabetes, Medicare covers a screening blood sugar test to check for diabetes. You are considered at risk if you have any of the following: high blood pressure, dyslipidemia (history of abnormal cholesterol and triglyceride levels), obesity, or a history of high blood sugar. Other risk factors may also qualify you for this test and based on the results, you may be eligible for up to two screenings each year. Medicare also covers certain supplies and self-management training to find and treat diabetes.

Glaucoma Tests - Glaucoma is an eye disease caused by high pressure in the eye. It can cause you to gradually lose sight without warning and often without symptoms. The best way for people at high risk for glaucoma to protect themselves is to have regular eye exams.

Medical Nutrition Therapy - Medical nutrition therapy services are also covered for people with diabetes or renal disease when referred by a doctor. These services can be given by a registered dietitian or Medicare-approved nutrition professional and include a nutritional assessment and counseling to help you manage your diabetes or kidney disease.